Born Too Soon

The Global Action Report on Preterm Birth

Born Too Soon

ooN The GloBal acTIoN reporT oN preTerm BIrTh

report is written in support of the Global Strategy for Women’s and children’s health and the efforts of every Woman every child, led by UN Secretary-General Ban Ki-moon.

cover photo: Colin Crowley/Save the Children

The Global Action Report on Preterm Birth

2012

Born Too Soon

WHO Library Cataloguing-in-Publication Data:

Born too soon: the global action report on preterm birth.

1.Premature birth – prevention and control. 2.Infant, premature. 3.Infant mortality – trends. 4.Prenatal care. 5.Infant care.

I.World Health Organization.

ISBN 978 92 4 150343 3 (NLM classification: WQ 330)

@ World Health Organization 2012

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Request for copies

North America: globalprograms@marchofdimes.com Rest of the world: pmnch@who.int

Recommended citation:

March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon: The Global Action Report on Preterm Birth. Eds CP Howson, MV Kinney, JE Lawn. World Health Organization. Geneva, 2012.

vi Main abbreviations

vi Country groups used in the report vii Foreword

viii Commitments to preterm birth 1 Executive summary

8 Chapter 1. Preterm birth matters

16 Chapter 2. 15 million preterm births: priorities for action based on national, regional and global estimates

32 Chapter 3. Care before and between pregnancy 46 Chapter 4. Care during pregnancy and childbirth 60 Chapter 5. Care for the preterm baby

78 Chapter 6. Actions: everyone has a role to play

102 References

112 Acknowledgements

Photo: March of Dimes

Photo: © Name

Main Abbreviations

Country groups used in the report

ANC Antenatal Care BMI Body Mass Index

CHERG Child Health Epidemiology Research Group CPAP Continuous positive airway pressure DHS Demographic and Health Surveys EFCNI European Foundation for the Care of

Newborn Infants

GAPPS Global Alliance to Prevent Prematurity and Stillbirth GNI Gross National Income

HIV Human Immunodeficiency Virus

IMCI Integrated Management of Childhood Illnesses IPTp Intermittent presumptive treatment during

pregnancy for malaria IUGR Intrauterine growth restriction IVH Intraventricular hemorrhage KMC Kangaroo Mother Care LAMP Late and moderate preterm LBW Low birthweight

LiST Lives Saved Tool LMP Last menstrual period

MDG Millennium Development Goal MMR Maternal mortality ratio MOD March of Dimes Foundation NCD Non-communicable disease NGO Non-governmental organization NICU Neonatal intensive care unit NIH National Institutes of Health, USA NMR Neonatal mortality rate

PMNCH Partnership for Maternal, Newborn & Child Health PREBIC International PREterm BIrth Collaborative pPROM Prelabor premature rupture of membranes RCT Randomized controlled trials

RDS Respiratory distress syndrome

RMNCH Reproductive, maternal, newborn and child health SNL Saving Newborn Lives, Save the Children STI Sexually transmitted infection

UN United Nations

UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization

Millennium Development Goal regions: Central & Eastern Asia, Developed, Latin America & the Caribbean, Northern Africa & Western Asia, Southeastern Asia & Oceania, Southern Asia, sub-Saharan Africa. For countries see http://mdgs.un.org

World Bank country income classification: High-, middle- and low-income countries (details in Chapter 1)

Countdown to 2015 priority countries: 75 countries where more than 95% of all maternal and child deaths occur (full list in Chapter 6)

Photo: © Name

Foreword

The response to the 2010 launch of the Every Woman Every Child effort has been very encour- aging. Government leaders, philanthropic organizations, businesses and civil society groups around the world have made far-reaching commitments and contributions that are catalyzing action behind the Global Strategy for Women’s and Children’s Health and the health-related Millennium Development Goals (MDGs). Born Too Soon is yet another timely answer by partners that showcases how a multi-stakeholder approach can use evidence-based solutions to ensure the survival, health and well-being of some of the human family’s most defenseless members.

Every year, about 15 million babies are born prematurely — more than one in 10 of all babies born around the world. All newborns are vulnerable, but preterm babies are acutely so. Many require special care simply to remain alive. Newborn deaths — those in the first month of life — account for 40 per cent of all deaths among children under five years of age. Prematurity is the world’s single biggest cause of newborn death, and the second leading cause of all child deaths, after pneumonia. Many of the preterm babies who survive face a lifetime of disability.

These facts should be a call to action. Fortunately, solutions exist. Born Too Soon, produced by a global team of leading international organizations, academic institutions and United Nations agencies, highlights scientifically proven solutions to save preterm lives, provide care for preterm babies and reduce the high rates of death and disability.

Ensuring the survival of preterm babies and their mothers requires sustained and significant financial and practical support. The Commission on Information and Accountability for Women’s and Children’s Health, established as part of the Every Woman Every Child effort, has given us new tools with which to ensure that resources and results can be tracked. I hope this mechanism will instill confidence and lead even more donors and other partners to join in advancing this cause and accelerating this crucial aspect of our work to achieve the MDGs by the agreed deadline of 2015.

I launched the Global Strategy for Women’s and Children’s Health to draw attention to the urgency of saving the lives of the world’s most vulnerable people. I was driven not only by my concern, but by the fundamental reality that what has been lacking in this effort is the will, not the techniques, technologies or science. We know what to do. And we all have a role to play. Let us act on the findings and recommendations of this report. Let us change the future for millions of babies born too soon, for their mothers and families, and indeed for entire countries. Enabling infants to survive and thrive is an imperative for building the future we want.

Ban Ki-moon

The United Nations Secretary-General

The Association of Women’s Health, Obstetric and Neonatal Nurses’ Late Preterm Infant (LPI) Research- Based Practice Project, supported by Johnson & Johnson, will raise awareness of risks associated with late preterm birth, help reduce complications and improve care.

Outcomes include expanding the body of knowledge about LPI morbidity and increasing nurses’ ability to provide appropriate care. An Implementation Tool Kit will include strategies for effective nursing care as pivotal to eliminating preventable late preterm infant complications.

The Bill & Melinda Gates Foundation commits to reducing preterm birth through its Family Health agenda with grants of $1.5 billion from 2010 to 2014 to support three core areas:

coverage of interventions that work (e.g. Kangaroo Mother Care, antenatal corticosteroids); research and development of new interventions; and tools to better understand the burden and reduce the incidence of preterm birth, such as the Lives Saved Tool and MANDATE Project.

CORE Group will increase awareness about practical steps to prevent and treat preterm complications to the CORE Group’s Community Health Network, a community of practice of over 70 member and associate organizations, by disseminating this report and other state-of-the-art information through its working groups, listservs, and social media channels that reach 3,000 health practitioners around the world.

The Council of International Neonatal Nurses, Inc.

is strongly committed to increasing awareness of the dan- gers of premature birth and in supporting the actions in this report, Born Too Soon, and to the prevention and care of babies not only because of the key role that neonatal nurses play in their early lives but also because of the urgent action needed in reducing the rates of preterm birth and related mortality and disability.

DFID has set out clear plans to help improve the health of women and young children in many of the poorest countries and help save the lives of at least 250,000 newborn babies and 50,000 women during pregnancy and childbirth by 2015.

The UK’s commitments to improve the lives of women and children can be found in “UK AID: Changing lives, delivering results”, on DFID’s website.

The European Foundation for the Care of Newborn Infants in partnership with the Global Alliances, March of Dimes and other organizations, looks forward to reducing the severe toll of prematurity in all countries. As prematurity poses a serious and growing threat to the health and well- being of the future European population, EFCNI commits to making maternal and newborn health a policy priority in Europe by the year 2020.

The Flour Fortification Initiative joins efforts to see babies delivered at full term through communication, advocacy and technical support for increased fortification of foods in developing countries. Studies indicate a link between maternal iron deficiency anemia in early pregnancy and a greater risk of preterm delivery, and insufficient maternal folic acid can lead to neural tube defects, one cause of preterm deliveries. Projects include campaigns in Nigeria and Ethiopia and support to Uganda, Mozambique and elsewhere.

The GAVI Alliance will help developing countries advance the control and elimination of rubella and congenital rubella syndrome through immunisation. Each year, 110,000 babies are born with severe birth defects from congenital rubella syndrome because their mothers were infected with rubella virus early in pregnancy. About 80% of those babies are born in GAVI-eligible countries. By 2015, over 700 million children will be immunised through campaigns and routine immunisation with combined measles-rubella vaccine.

Commitments to preterm birth

In support of the Every Woman Every Child effort to advance the Global Strategy on Women’s and Children’s Health, more than 30 organizations have provided commitments to advance the prevention and care of preterm birth. These statements will now become part of the overall set of commitments to the Global Strategy, and will be monitored annually through 2015 by the independent Expert Review Group established by the Commission on Information and Accountability for Women’s and Children’s Health. For the complete text of each commitment, please visit: http://

everywomaneverychild.org/borntoosoon

ents

Foundation will fund up to US$ 800,000 over the next two years for research on the link between the use of traditional cookstoves and child survival. It will focus on adverse pregnancy outcomes, including low birth weight, pre-term birth, and birth defects; and/or severe respiratory illness including pneumonia in children under-five years of age.

This research will hopefully identify new interventions to reduce premature births worldwide.

Global Alliance to Prevent Prematurity and Stillbirth (GAPPS) commits to leading global efforts to discover the causes and mechanisms of preterm birth through the Preventing Preterm Birth initiative and operating the GAPPS Repository. GAPPS commits to expanding collaborative efforts for a global advocacy campaign to promote the critical need for strategic investment in research and catalyze fund- ing for it. GAPPS will work to make every birth a healthy birth.

The Home for Premature Babies (HPB) is China’s largest association of those affected by preterm birth. We unite 400,000 families and work to raise awareness and provide rehabilitation service for preterm infants. Within 3 to 5 years we plan to double our membership; publish a monthly magazine on premature infants; establish a medical tele- consultation system; develop and implement a continuing education program for paediatricians; and establish a branch of HPB in every province in China.

The International Confederation of Midwives will maintain its commitment to working towards enhancing the reproductive health of women, and the health of their newborn, including preventing preterm birth and care for premature babies, by promoting autonomous midwives as the most appropriate caregivers for childbearing women and their newborn and midwifery services as the most effective means of achieving MDGs 4&5 for child survival and maternal health.

The International Pediatric Association’s (IPA) 177 pediatric societies support neonatal, child, adolescent and maternal health through policy advocacy, planning, expanded health services, pregnancies that are supported by the entire community and safe delivery for mother and baby. IPA will feature Born Too Soon on its website and in the organizational newsletter, encouraging national pediatric societies to feature this fundamental topic in educational meetings and policy discussions.

partner countries in building and strengthening systems for a “Continuum of Care for Maternal and Child Health”

through technical cooperation US$ 25 million and grant aid projects of around US$ 13 million annually, and initiat- ing concessional loans to support partner countries to achieve MNCH-related MDGs. Japan’s Global Health Policy 2011-2015 commits to saving approximately 11.3 million children’s lives and 430,000 maternal lives in cooperation with other donors.

The Johns Hopkins Bloomberg School of Public Health is committed to strengthening evidence on the extent and causes of preterm births globally and to developing cultur- ally and economically appropriate interventions to reduce the burden of premature birth around the world. We also commit to working with governments and their partners on the translation of evidence into effective policies and programs. We aim to achieve measurable results of our efforts by 2015.

The Kinshasa School of Public Health in the Democratic Republic of the Congo, with its partner the University of North Carolina, has joined the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS) and submitted a proposal aimed at preventing preterm birth. The goal of this initiative is to encourage scientific studies that will lead to or refine preventive interventions for preterm birth and still birth related to preterm birth, primarily in developing world settings.

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Photo: © March of Dimes

The London School of Hygiene & Tropical Medicine (LSHTM) has a strategic long-term commitment to research through the MARCH Centre for Maternal, Reproductive and Child Health and will continue to improve the data and evidence base and to advance and evaluate innovative solutions for the poorest women and babies. LSHTM will work with partners to increase the numbers and capacity of scientists and institutions in the most affected countries.

The March of Dimes commits to its Prematurity Campaign through 2020, devoting approximately $20 million annually to research into the causes of premature birth; collaboration with key stakeholders to enhance quality and accessibility of prenatal and newborn care; education and awareness cam- paigns to identify and reduce risk of prematurity. March of Dimes has worked with parent groups to create and promote World Prematurity Day, November 17, to advocate for further action, including the recommendations in this publication.

Paediatrics and Child Health, College of Medicine, University of Malawi is committed to improving the care of newborns in Malawi. Specific efforts are being made to help premature babies with respiratory distress by introduc- ing appropriate technologies and enhancing the Kangaroo Mother Care through teaching and outreach.

The Partnership for Maternal, Newborn & Child Health commits to developing a companion knowledge summary to this report; supporting preterm private sector commitments linked to the Commission on Life-saving Commodities for Women and Children; promoting World Prematurity Day, November 17; and tracking yearly progress of these com- mitments for the annual report of the independent Expert Review Group related to the Global Strategy and the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health.

Preterm Birth International Collaborative (PREBIC) supports prematurity prevention programs by organizing workshops for scientists and clinicians around the globe aimed to build consortiums of investigators. These consor- tiums identify knowledge gaps in various areas of preterm birth research and develop protocols to fill these gaps.

PREBIC organizes scientific symposiums in association with major Obstetrics Congresses to educate health care professionals regarding ongoing preterm birth research.

PREBIC’s research core supports investigators in high throughput research.

The Preterm Clinical Research Consortium of Peking University Center of Medical Genetics (PUCMG) will work closely with global, regional and national communi- ties and organizations to raise public awareness of the toll of preterm birth in China, and continue existing programs directed at reducing the rate of preterm birth and associated mortality and disability. Within three years, PUCMG will have completed a prospective cohort study identifying major risk factors for preterm birth in the Chinese population.

Save the Children commits to working with partners to make preventable newborn deaths unacceptable and to advance implementation of maternal and newborn services, enabling frontline health workers and empowering families to provide the care every newborn needs. By 2015, Save the Children will promote increases in equitable access for high-impact interventions for preterm babies including:

antenatal corticosteroids to strengthen premature babies’

lungs; Kangaroo Mother Care; neonatal resuscitation;

improved cord care; breastfeeding support; and effective treatment of neonatal infections.

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COMMITMENTS

TO PRETERM BIRTH

ents

by capacity building of the midwifery workforce for this purpose. As partners in the global movement to reduce maternal, new-born and child mortality, Sida will advocate to increase awareness of the need for professional midwives.

Moreover to improve education and working conditions to allow midwives to play a significant role in the prevention of premature birth and competent care for the pre-term baby.

UNFPA commits to working with countries to address the following priorities by the end of 2013: strengthening mid- wifery in 40 countries; strengthening emergency obstetric and newborn care in 30 countries; ensuring no stock-outs of contraceptives at service-delivery points for at least six months in at least 10 countries; and supporting key demand generation interventions, especially for modern contracep- tives, in at least 35 countries.

UNICEF commits to supporting global advocacy efforts;

helping governments implement and scale up preterm and newborn care interventions, including community programs to improve equitable access for the most disadvantaged mothers and babies; working with WHO and countries to strengthen the availability and quality of data on preterm births and provide updated analyses and trends every three to five years; and advancing the procurement and supply of essential medicines and commodities for preterm births, neonatal illnesses and deaths.

University of the Philippines Manila commits to continue research and advocacy work on models for precon-

ception care. The current project will produce counseling modules for the workplace, com-

munity level, and youth peer counseling, and is being piloted city-wide in Lipa City in cooperation with the Local

Government.

Department of Obstetrics & Gynecology, Maternal-Fetal Medicine Division, studies preterm-birth risk factors, pathophysiology, pathways, and designs prevention strate- gies. In addition, the division is dedicated to understanding causes and consequences of fetal programming due to preterm birth.

USAID is committed to saving newborn lives in an effort to reduce under-five mortality by 35 percent. We will support high-impact affordable interventions that can prevent and manage complications associated with preterm birth. This includes service delivery approaches, innovations to reduce maternal and neonatal mortality, global guidelines and poli- cies for governments, and engaging the private sector and global public-private alliances to harness the resources and creativity of diverse organizations.

Women Deliver commits to making family planning one of the key themes of its international conference Women Deliver 2013 in Kuala Lumpur, Malaysia, and developing conference sessions on newborn health. Spacing births through voluntary family planning is key to reducing the risk of preterm births. The global conference will explore solutions on how to reduce the unmet need for family planning by 100 million women by 2015, and 215 million women by 2020.

The World Health Organization is committed to working with countries on the availability and quality of data; regu- larly providing analyses of global preterm birth levels and trends every three to five years; working with partners on research into the causes, prevention and treatment of pre- term birth; updating clinical guidelines including “Kangaroo Mother Care”, feeding low birth-weight babies, treating infections and respiratory problems, and home-based follow-up care; as well as tools to improve health workers’

skills and assess quality of care.

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Photo: © March of Dimes

ADVANCE TO PREVENTION

AND CARE

Photo: © Name

“We held our daughter in our arms... we shed our tears, said goodbye and went home to tell our little boy that he wouldn’t have a sister.” — Doug, USA

“I felt devastated watching my newborn fight for his life, yet our beautiful baby, Karim, with the help of his dedicated medical support team, continued to fight and survive.” — Mirvat, Lebanon

“Weighing less than a packet of sugar, at only 2.2 lbs (about 1kg), Tuntufye survived with the help of Kangaroo Mother Care.”

— Grace, Malawi Grace from Malawi gave birth

to her daughter, Tuntufye, 8 weeks early (pictured above).

She survived against the odds and is now a healthy young girl (pictured below).

Photo: William Hirtle/Save the Children Photo: Save the Children Photo: Save the Children

Behind every statistic is a story

The power of parent groups

Parents affected by a preterm birth are a powerful advocacy force around the world.

Increasingly, parents are organizing among themselves to raise awareness of the problem, facilitate health professional training and public education, and improve the quality of care for premature babies. Parent groups are uniquely positioned to bring visibility to the problem of preterm birth in their countries and regions and to motivate government action at all levels.

The European Foundation for the Care of Newborn Infants is an example of an effective parent group that is successfully increasing visibility, political attention and policy change for preterm birth across Europe (more information in Chapter 5).

The Home for Premature Babies is a parent group taking action forward in China, provid- ing nationwide services in support of prevention and care (more information in Chapter 6).

“As we have experienced in China, groups of parents affected by preterm birth can be an independent and uniquely powerful grassroots voice calling on government, professional organizations, civil society, the business community and other partners in their countries to work together to prevent prematurity, improve care of the preterm baby and help sup- port affected families.” Dr. Nanbert Zhong, Chair, Advisory Committee for Science and International Affairs, Home for Premature Babies

STORY

Behind every statistic is a

Photo: © Name

E Summary

Headline Messages

15 million babies are born too soon every year

• More than 1 in 10 babies are born preterm, affecting families all around the world.

• Over 1 million children die each year due to complica- tions of preterm birth. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems.

Rates of preterm birth are rising

• Preterm birth rates are increasing in almost all countries with reliable data.

• Prematurity is the leading cause of newborn deaths (babies in the first 4 weeks of life) and now the second- leading cause of death after pneumonia in children under the age of 5.

• Global progress in child survival and health to 2015 and beyond cannot be achieved without addressing preterm birth.

• Investment in women’s and maternal health and care at birth will reduce stillbirth rates and improve outcomes for women and newborn babies, especially those who are premature.

Prevention of preterm birth must be accelerated

• Family planning and increased empowerment of women, especially adolescents, plus improved quality of care before, between and during pregnancy can help to reduce preterm birth rates.

• Strategic investments in innovation and research are required to accelerate progress.

Premature babies can

be saved now with feasible, cost-effective care

• Historical data and new analyses show that deaths from preterm birth complications can be reduced by over three-quarters even without the availability of neonatal intensive care.

• Inequalities in survival rates around the world are stark: half of the babies born at 24 weeks (4 months early) survive in high-income countries, but in low- income settings, half the babies born at 32 weeks (two months early) continue to die due to a lack of feasible, cost-effective care, such as warmth, breastfeeding support, and basic care for infections and breathing difficulties.

• Over the last decade, some countries have halved deaths due to preterm birth by ensuring frontline workers are skilled in the care of premature babies and improving supplies of life-saving commodities and equipment.

Everyone has a role to play

• Everyone can help to prevent preterm births and improve the care of premature babies, accelerating progress towards the goal of halving deaths due to preterm birth by 2025.

• The Every Woman Every Child effort, led by UN Secretary-General Ban Ki-moon, provides the frame- work to coordinate action and ensure accountability.

Definition of preterm birth: Babies born alive before 37 weeks of pregnancy are completed.

Sub-categories of preterm birth, based on weeks of gestational age:

Extremely preterm (<28 weeks) Very preterm (28 to <32 weeks)

Moderate to late preterm (32 to <37 weeks)

Note: Births at 37 to 39 weeks still have suboptimal outcomes, and induction or cesarean birth should not be planned before 39 completed weeks unless medically indicated

Photo: Jenn Warren/Save the Children

Inform

Why do preterm births matter?

Urgent action is needed to address the estimated 15 million babies born too soon, especially as preterm birth rates are increasing each year (Figure 1). This is essential in order to progress on the Millennium Development Goal (MDG) for child survival by 2015 and beyond, since 40% of under-five deaths are in newborns, and it will also give added value to maternal health (MDG 5) investments (Chapter 1). For babies who survive, there is an increased risk of disability, which exacts a heavy load on families and health systems.

Why does preterm birth happen?

Preterm birth occurs for a variety of reasons (Chapter 2).

Some preterm births result from early induction of labor or cesarean birth whether for medical or non-medical reasons. Most preterm births happen spontaneously.

Common causes include multiple pregnancies, infections and chronic conditions, such as diabetes and high blood pressure; however, often no cause is identified. There is also a genetic influence. Better understanding of the causes and mechanisms will advance the development of prevention solutions.

Where and when?

Over 60% of preterm births occur in Africa and South Asia (Figure 1). The 10 countries with the highest numbers include Brazil, the United States, India and Nigeria, demonstrating that preterm birth is truly a global problem. Of the 11 coun- tries with preterm birth rates of over 15%, all but two are in sub-Saharan Africa (Figure 2). In the poorest countries, on average, 12% of babies are born too soon compared with 9% in higher-income countries. Within countries, poorer families are at higher risk.

0 1000 2000 3000 4000 5000 6000

Northern Africa &

Western Total number Asia

of births in region (thousands)

% preterm

Number of preterm births (thousands)

Latin America

& the Caribbean

Developed Central

& Eastern Asia

South- Eastern

Asia &

Oceania

Saharan Sub- Africa

Southern Asia

n=8,400

8.9% n=10,800

8.6% n=14,300

8.6% n=19,100

7.4% n=11,200

13.5% n=32,100

12.3% n=38,700 13.3%

Preterm births <28 weeks Preterm births 28 to <32 weeks Preterm 32 to <37 weeks

Based on Millennium Development Goal regions.

Source: Blencowe et al National, regional and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications

Figure 1: Preterm births by gestational age and region for 2010 Preterm birth by the numbers:

• 15 million preterm births every year and rising

• 1.1 million babies die from preterm birth complications

• 5-18% is the range of preterm birth rates across 184 countries of the world

• >80% of preterm births occur between 32-37 weeks of gestation and most of these babies can survive with essential newborn care

• >75% of deaths of preterm births can be prevented without intensive care

• 7 countries have halved their numbers of deaths due to preterm birth in the last 10 years

Photo: March of Dimes

E Summary

Of 65 countries with reliable trend data, all but 3 show an increase in preterm birth rates over the past 20 years.

Possible reasons for this include better measurement and improved health such as increases in maternal age and underlying maternal health problems such as diabetes and high blood pressure; greater use of infertility treatments leading to increased rates of multiple pregnancies; and changes in obstetric practices such as more caesarean births before term.

There is a dramatic survival gap for premature babies depending on where they are born. For example, over 90%

of extremely preterm babies (<28 weeks) born in low-income countries die within the first few days of life; yet less than 10% of babies of this gestation die in high-income settings, a 10:90 survival gap.

Counting preterm births

The preterm birth rates presented in this report are esti- mated based on data from national registeries, surveys and special studies (Blencowe et al., 2012). Standard definitions of preterm birth and consistency in reporting pregancy outcomes are essential to improving the quality of data and ensuring that all mothers and babies are counted.

Source: Blencowe et al National, regional and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications.

Note: rates by country are available on the accompanying wall chart.

Not applicable= non WHO Members State

Figure 2: Global burden of preterm birth in 2010

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which

there may not yet be full agreement. © WHO 2012. All rights reserved.

Data Source: World Health Organization Map Production: Public Health Information and Geographic Information Systems (GIS) World Health Organization

0 1,500 2,500 5,000 kilometers

Preterm birth rate, year 2010

<10%

10 - <15%

15% or more Data not available Not applicable

11 countries with preterm birth rates over 15% by rank:

1. Malawi 2. Congo 3. Comoros 4. Zimbabwe 5. Equatorial Guinea 6. Mozambique 7. Gabon 8. Pakistan 9. Indonesia 10. Mauritania 11. Botswana

Photo: Pep Bonet/Noor/Save the Children

Empowering and educating girls as well as providing care to women and couples before and between pregnancies improve the opportunity for women and couples to have planned pregnancies increasing chances that women and their babies will be healthy, and survive. In addition, through reducing or addressing certain risk factors, preterm birth prevention may be improved (Chapter 3).

Invest and plan

Adolescent pregnancy, short time gaps between births, unhealthy pre-pregnancy weight (underweight or obesity), chronic disease (e.g., diabetes), infectious diseases (e.g., HIV), substance abuse (e.g., tobacco use and heavy alcohol use) and poor psychological health are risk factors for preterm birth. One highly cost-effective intervention is family planning, especially for girls in regions with high rates of adolescent pregnancy. Promoting better nutrition, environmental and occupational health and education for women are also essential. Boys and men, families and communities should be encouraged to become active partners in preconception care to optimize pregnancy outcomes.

Implement priority, evidence-based interventions

• Family planning strategies, including birth spacing and provision of adolescent-friendly services;

• Prevention, and screening/ management of sexually transmitted infections (STIs), e.g., HIV and syphilis;

• Education and health promotion for girls and women;

• Promoting healthy nutrition including micronutrient fortification and addressing life-style risks, such as smoking, and environmental risks, like indoor air pollution.

Inform and improve program coverage and quality

Consensus around a preconception care package and the testing of this in varying contexts is an important research need. When researching pregnancy outcomes or assessing reproductive, maternal, newborn and child health strategies, preterm birth and birthweight measures should be included as this will dramatically increase the information available to understand risks and advance solutions.

Premature baby care

The survival chances of the 15 million babies born preterm each year vary dramatically depending on where they are born (Chapter 5). South Asia and sub-Saharan Africa account for half the world’s births, more than 60% of the world’s preterm babies and over 80% of the world’s 1.1 million deaths due to preterm birth complications. Around half of these babies are born at home. Even for those born in a health clinic or hospital, essential newborn care is often lacking.

The risk of a neonatal death due to complications of preterm birth is at least 12 times higher for an African baby than for a European baby. Yet, more than three-quarters of premature babies could be saved with feasible, cost-effective care,

and further reductions are possible through intensive neonatal care.

Invest and plan

Governments, together with civil society, must review and update existing policies and programs to integrate high-impact care for premature babies within existing programs for maternal, newborn and child health. Urgent increases are needed in health system capacity to take care of newborns particularly in the field of human resources, such as training nurses and midwives for newborn and premature baby care, and ensuring reliable supplies of commodities and equipment. Seven middle-income countries have halved their neonatal deaths from preterm birth through strategic scale up of referral-level care.

Photo: Susan Warner/ Save the ChildrenPhoto:Sanjana Shrestha/Save the Children

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Pregnancy and childbirth are critical windows of opportunity for providing effective interventions to improve maternal health and reduce mortality and disability due to preterm birth. While many countries report high coverage of antenatal care and increasing coverage of facility births, significant gaps in coverage, equity and quality of care remain between and within countries, including high-income countries (Chapter 4).

Invest and plan

Countries need to ensure universal access to comprehensive antenatal care, quality childbirth services and emergency obstetric care. Workplace policies are important to promote healthy pregnancies and reduce the risk of preterm birth, including regulations to protect pregnant women from physically-demanding work. Environmental policies to reduce exposure to potentially harmful pollutants, such as from traditional cookstoves and secondhand smoke, are also necessary.

Implement priority, evidence-based interventions

• Ensure antenatal care for all pregnant women, including screening for, and diagnosis and treatment of infections such as HIV and STIs, nutritional support and counseling;

• Provide screening and management of pregnant women at higher risk of preterm birth, e.g., multiple pregnancies, diabetes, high blood pressure, or with a history of previous preterm birth;

• Effectively manage preterm labor, especially provision of antenatal corticosteroids to reduce the risk of breathing difficulties in premature babies. This intervention alone could save around 370,000 lives each year;

• Promote behavioral and community interventions to reduce smoking, secondhand smoke exposure, and other pollutants; and prevention of violence against women by intimate partners;

• Reduce non-medically indicated inductions of labor and cesarean births especially before 39 completed weeks of gestation.

Inform and improve program coverage and quality

Better measurement of antenatal care services will improve monitoring coverage and equity gaps of high-impact interventions. Implementation research is critical for informing efforts to scale up effective interventions and improve the quality of care. Discovery research on normal and abnormal pregnancies will facilitate the development of preventive interventions for universal application.

Implement priority, evidence-based interventions

• Essential newborn care for all babies, including thermal care, breastfeeding support, and infection prevention and management and, if needed, neonatal resuscitation;

• Extra care for small babies, including Kangaroo Mother Care (carrying the baby skin-to-skin, additional support for breastfeeding), could save an estimated 450,000 babies each year;

• Care for preterm babies with complications:

• Treating infections, including with antibiotics;

• Safe oxygen management and supportive care for respiratory distress syndrome, and, if appropriate and available, continuous positive airway pressure and/or surfactant;

• Neonatal intensive care for those countries with lower mortality and higher health system capacity.

Inform and improve program coverage and quality

Innovation and implementation research is critical to accelerate the provision of care for premature babies, especially skilled human resources and robust, reliable technologies. Monitoring coverage of preterm care interventions, including Kangaroo Mother Care, as well as addressing quality and equity requires urgent attention. Better tracking of long-term outcomes, including visual impairment for surviving babies, is critical.

Photo: Aubrey Wade/ Save the ChildrenPhoto: Aubrey Wade/ Save the Children Photo:March of Dimes

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Priority interventions, packages and strategies for preterm birth

Reducing the burden of preterm birth has a dual track: prevention and care.

Interventions with proven effect for prevention are clustered in the preconception, between pregnancy and pregnancy periods as well as during preterm labor (Figure 3).

Interventions to reduce death and disability among premature babies can be applied both during labor and after birth. If interventions with proven benefit were universally available to women and their babies (i.e., 95% cover- age), then almost 1 million premature babies could be saved each year.

A global action agenda for research

Preterm birth has multiple causes; therefore, solutions will not come through a single discovery but rather from an array of discoveries addressing multiple biological, clinical, and social-behavioral risk factors. The dual agenda of preventing preterm birth and addressing the care and survival gap for premature babies requires a comprehensive research strat- egy, but involves different approaches along a pipeline of innovation. The pipeline starts from describing the problem and risks more thoroughly, through discovery science to understanding causes, to developing new tools, and finally to research the delivery of these new tools in various health system contexts. Research capacity and leadership from low- and middle-income countries is critical to success and requires strategic investment.

For preterm prevention research, the greatest emphasis should be on descriptive and discovery learning, under- standing what can be done to prevent preterm birth in various contexts. While requiring a long-term investment, risks for preterm birth and the solutions needed to reduce these risks during each stage of the reproductive, maternal, newborn and child health continuum, are becoming increas- ingly evident (Chapters 3-5). However, for many of these risks such as genital tract infections, we do not yet have effective program solutions for prevention.

For premature baby care, the greatest emphasis should be on development and delivery research, learning how to implement what is known to be effective in caring for prema- ture babies, and this has a shorter timeline to impact at scale (Chapter 6). Some examples include adapting technologies such as robust and simplified devices for support for babies with breathing difficulties, or examining the roles of different health care workers (e.g., task shifting).

PREVENTION OF PRETERM BIRTH

• Preconception care package, including family planning (e.g., birth spacing and adolescent- friendly services), education and nutrition especially for girls, and STI prevention

• Antenatal care packages for all women, including screening for and management of STIs, high blood pressure and diabetes; behavior change for lifestyle risks; and targeted care of women at increased risk of preterm birth

• Provider education to promote appropriate induction and cesarean

• Policy support including smoking cessation and employment safeguards of pregnant women

CARE OF THE PREMATURE BABY

• Essential and extra newborn care, especially feeding support

• Neonatal resuscitation

• Kangaroo Mother Care

• Chlorhexidine cord care

• Management of premature babies with complications, especially respiratory distress syndrome and infection

• Comprehensive neonatal intensive care, where capacity allows MANAGEMENT

OF PRETERM LABOR

• Tocolytics to slow down labor

• Antenatal corticosteroids

• Antibiotics for pPROM

MORTALITY REDUCTION AMONG BABIES BORN PRETERM REDUCTION OF

PRETERM BIRTH

Description Discovery Development Delivery

premature babies

Photo: Bill & Melinda Gates Foundation/Joan SullivanPhoto: MRC/Allen Jefthas Photo: Rice 360 Photo: Michael Bisceglie/Save the Children

E Summary

Goal by 2025

Since prematurity contributes significantly to child mortality, Born Too Soon presents a new goal for the reduction of deaths due to complications of preterm birth.

• For countries with a current neonatal mortality rate level of more than or equal to 5 per 1,000 live births, the goal is to reduce the mortality due to preterm birth by 50% between 2010 and 2025.

• For countries with a current neonatal mortality rate level of less than 5 per 1,000 live births, the goal is to eliminate remaining preventable preterm deaths, focusing on equitable care for all and quality of care to minimize long-term impairment.

After the publication of this report, a technical expert group will be convened to establish a goal for reduction of preterm birth rate by 2025, for announcement on World Prematurity Day 2012.

Details of these goals are given in Chapter 6 of the report.

Gover nments and policymakersDonor countries

and philanthr opy

UN and othermultilateralsCivil society Business

community Health car

e workers

& associationsAcademics andresear chers

Invest Ensure preterm interventions and research given proportional focus, so funding is aligned with health burden

Implement

Plan and implement preterm birth strategies at global and country level and align on preterm mortality reduction goal

Introduce programs to ensure coverage of evidence-based interventions, particularly to reduce preterm mortality

Inform

Significantly improve preterm birth reporting by aligning on consistent definition and more consistently capturing data

Raise awareness of preterm birth at all levels as a central maternal, newborn and child health issue

Innovate

Perform research to support both prevention and treatment agendas

Pursue implementation research agenda to understand how best to scale up interventions

Continue support for Every Woman Every Child and other reproductive, maternal, newborn and child health efforts, which are inextricably linked with preterm birth

Ensure accountability of stakeholders across all actions Primary

role Secondary role:

supporting effort Figure 4: Shared actions to address preterm births

Everyone has a role to play...

to reach every woman, every newborn, every child

Reducing preterm births and improving child survival are ambitious goals. The world has made much progress reducing maternal, newborn and child deaths since the MDGs were set, but accelerated progress will require even greater collaboration and coordination among national and local governments, donors, UN and other multilaterals, civil society, the business community, health care professionals and researchers, working together to advance investment, imple-

mentation, innovation and information-sharing (Figure 4, Chapter 6). Photo: Ritam Banerjee for Getty Images/Save the Children

Photo: Michael Bisceglie/Save the Children

P r e t e r m B ir t h m a t t e

Photo: © March of Dimes

m Birth matters

— Christopher Howson, Mary Kinney, Joy Lawn

Preterm birth matters

The numbers

More than 1 in 10 of the world’s babies born in 2010 were born prematurely, making an estimated 15 million preterm births (defined as before 37 weeks of gestation), of which more than 1 million died as a result of their prematurity (Chapter 2) (Blencowe et al., 2012). Prematurity is now the second-leading cause of death in children under 5 years and the single most important cause of death in the critical first month of life (Liu et al., 2012). For the babies who sur- vive, many face a lifetime of significant disability. Given its frequent occurrence, it is likely that most people will experi- ence the challenge, and possible tragedy, of preterm birth at some point in their lives, either directly in their families or indirectly through friends.

Prematurity is an important public health priority in high- income countries.¹ However, lack of data on preterm birth at the country level has hampered action in low- and middle-income countries. Born Too Soon presents the first published country-level estimates on preterm birth. These estimates show that prematurity is rising in most countries where data are available (Blencowe et al., 2012). The reasons for the rise in prematurity, especially in the later weeks of pregnancy, are varied and are discussed in later chapters of the report.

The implications of being born too soon extend beyond the neonatal period and throughout the life cycle. Babies who are born before they are physically ready to face the world often require special care and face greater risks of seri- ous health problems, including cerebral palsy, intellectual impairment, chronic lung disease, and vision and hearing loss. This added dimension of lifelong disability exacts a high toll on individuals born preterm, their families and the communities in which they live (Institute of Medicine, 2007).

The global rise in non-communicable diseases (NCDs) such as diabetes and hypertension and their association with an

elevated risk of preterm birth also demand increased atten- tion to maternal health, including the antenatal diagnosis and management of NCDs and other conditions known to increase the risk of preterm birth (Chapter 4). Premature babies, in turn, are at greater risk of developing NCDs, like hypertension and diabetes, and other significant health conditions later in life, creating an intergenerational cycle of risk (Hovi et al., 2007). The link between prematurity and an increased risk of NCDs takes on an added public health importance when considering the reported increases in the rates of both worldwide. Currently, 9 million people under the age of 60 years die from NCDs per year, accounting for more than 63% of all deaths, with the greatest burden in Africa and other low-income regions (United Nations General Assembly, 2011).

The Millennium Development Goals and beyond

The substantial decline in high-income countries in mater- nal, newborn and child deaths in the early and middle 20th century was a public health triumph. Much of this decline was due to improvements in socioeconomic, sanitation and educational conditions and in population health, most notably a reduction in malnutrition and infectious diseases (Howson, 2000; World Bank, 1993). These advances in public health also resulted from strengthened political will prompted by public pressure, often by health professionals, who demanded attention to and investment in the neces- sary sanitary measures, drugs and technologies that were responsible for the decline in maternal and child mortality in industrialized countries in the 20th century (de Brouwere et al., 1998). Many low- and middle-income countries are now experiencing a similar “health transition,” defined as an “encompassing relationship among demographic, epidemiologic and health changes that collectively and independently have an impact on the health of a population, the financing of health care and the development of health systems” (Mosley et al., 1993).

1. This report uses the World Bank classification of national economies on the basis of gross national income (GNI) per head. Using 2010 GNI figures, the World Bank describes countries as low-income (<$1,005), lower middle-income ($1,006 to $3,975), upper middle-income ($3,976 to 12,275), or high-income (>$12,276) (World Bank, 2012). Low- and middle-income countries are sometimes referred to as developing and high-income economies as industrialized. Although convenient, these terms should not imply that all developing countries are experiencing similar development or that all industrialized countries have reached a preferred or final stage of development (World Bank, 2012).

Recent acceleration in mortality reduction for mothers and for children aged between 1 and 59 months has been driven, in part, by the establishment of the Millennium Development Goal (MDG) framework (UNICEF, 2011; WHO, 2010). Established by 189 member states in 2000 with a target date of 2015 (United Nations General Assembly, 2000), the eight interlinking global goals provide benchmarks by which to measure success (UN, 2011). As such, they have mobilized common action to acceler- ate progress for the world’s poorest families. These goals put reproductive, maternal, newborn and child health (RMNCH) on the global stage by raising their visibility politically and socially and helped unite the development community in a common framework for action. The need to monitor progress has also led to improved and more frequent use of health metrics and to collaboration and consensus on how to strengthen primary health care systems from community-based interventions to the first referral-level facility at which emergency obstetric care is available (Walley et al., 2008).

MDG 4 calls for a reduction in the under-5 mortality rate by two-thirds between 1990 and 2015 and MDG 5 for a reduc- tion in the maternal mortal-

ity ratio by three-quarters during the same period.

Even with the visibility and increased progress that MDGs 4 and 5 have brought to maternal and child survival, the rate of decline for mortality reduc- tions remains insufficient to reach the set targets, particularly in sub-Saharan Africa and South Asia (Figure 1.1). For example, only 35 developing coun- tries are currently on track to achieve the MD G 4 target in 2015 (UNICEF, 2011). One important bar- rier to progress on MDG 4 has been the failure to reduce neonatal deaths

and deaths from its single most important cause, prema- turity (Lawn et al., 2009). Child survival programs have primarily focused on important causes of death after the first 4 weeks of life such as pneumonia, diarrhea, malaria and vaccine-preventable conditions (Martines et al., 2005), resulting in a decline in under-5 mortality rates. While important, the concomitant lack of attention to important

100 90 80 70 60 50 40 30 20 10 0

1990 1995 2000 Year 2005 2009 2015

Mortality per 1,000 live births

Under-5 mortality rate (UN) Under-5 mortality rate (IHME) Neonatal mortality rate (UN) Neonatal mortality rate (IHME)

57

23 MDG 429 target

Figure 1.1: MDG 4 Progress

Figure 1.2: How the Millennium Development Goals Link to Prevention and Care of Preterm Births

2

ACHIEVE UNIVERSAL PRIMARY EDUCATION

4

REDUCE CHILD MORTALITY

5

IMPROVE MATERNAL HEALTH

6

COMBAT HIV / AIDS, MALARIA AND OTHER DISEASES

3

PROMOTE GENDER EQUALITY AND EMPOWER WOMEN

1

ERADICATE EXTREME POVERTY AND HUNGER

8

A GLOBAL PARTNERSHIP FOR DEVELOPMENT

7

ENSURE ENVIRONMENTAL SUSTAINABILITY

• Poverty is a risk factor for preterm birth

• Women who were underfed or stunted as girls are at higher risk of preterm birth

• Education especially of girls reduces adolescent pregnancy, which is a risk factor for preterm birth

• Age appropriate health educa- tion may reduce preconception risk factors

• Gender equality, education and empowerment of women improve their outcomes and their babies’ survival

• Identification of actions that key constituencies can take individually and together to mobilize resources, address commodity gaps and ensure accountability in support of RMNCH and preterm birth preven- tion and care

• Family planning to avoid adolescent pregnancy and promote spacing births reduces the risk of preterm birth

• Effective antenatal, obstetric and postnatal care for all pregnant women saves lives of mothers and babies

• Prevention and treatment before and during pregnancy of infectious and non-communicable diseases known to increase risk of preterm birth

• Ensured access to improved water and sanitation facilities to reduce transmission of infectious diseases

• Newborn deaths account for 40% of under-5 mortality, which is the indicator for MDG4. Deaths from preterm birth have risen and now are one of the leading causes of under-5 deaths.

Millenium Development

Goal Links to Preterm Birth

Millenium Development

Goal Links to Preterm Birth

Source: Adapted from Lawn et al., 2012. Data from UN Interagency Group for Child Mortality Estimates (UNICEF, 2011) and the Institute for Health Metrics and Evaluation (Lozano et al., 2011).

Note: MDG 4 target reflects a 2/3 reduction from the under-5 mortality rate in 1990.

Note: With thanks to Boston Consulting Group for assistance on this figure.